Pre Appointment Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneMedical history *Currently pregnantFiller or Neurotoxin within 2 weeks (please wait at least 2 weeks after injections)Cosmetic or surgical implantsEpilepsyTaking blood thinnersBlood borne illnessRecent infectionRecent surgery/injuryPainful head, neck or facial areaTMJHeadachesAllergyKeloidPhotosensitiveDiabetesRetinopathyOtherNone of the abovePlease check *I understand there is a $25 fee for late cancellationI have read the HIPPA/Safety/Risks pageSubmit